Why is the HIV epidemic in Eastern Europe and Central Asia the fastest growing in the world and what do we need to do to halt it? XIX International.

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Presentation on theme: "Why is the HIV epidemic in Eastern Europe and Central Asia the fastest growing in the world and what do we need to do to halt it? XIX International."— Presentation transcript:

1 Why is the HIV epidemic in Eastern Europe and Central Asia the fastest growing in the world and what do we need to do to halt it?XIX International AIDS Conference Regional Session on Eastern Europe and Central AsiaIt is a both a great honour and a matter of some regret that I am addressing you here today in Washington DC .An honour because my peers asked me to make this presentation, this is the major platform for raising the issues affecting my region and I am in the esteemed company of Ministers, prevention and treatment specialists, donors and activists from the Region.A regret because although globally the number of people newly infected with HIV is decreasing, in Eastern Europe and Central Asia it continues to rise at an alarming rate and while prevention and treatment coverage is increasing globally in my Region it has stagnated at shamefully low rates.I do not regret this opportunity to debate keys issues and solutions relating to poor access to treatment; vulnerability and marginalisation; service integration; co-infection and funding raised in the presentation.Martin C. Donoghoe on behalf of the XIX International AIDS Conference Regional Working Group for Eastern Europe and Central Asia

2 HIV epidemic in Europe still not under controlCumulative number of diagnosed cases (in thousands), WHO European Region, 1986–2010So what does the data tell us?First case reporting - By the end of 2010 [1] a total of cumulative HIV infections had been reported to WHO and the European Centre for Disease Prevention and Control (ECDC) [2].In addition at least cases, not included in the HIV surveillance report, have been diagnosed in the Russian Federation plus almost AIDS cases diagnosed in western European countries with no HIV surveillance data from before 2002–2004 [3].The total cumulative number of people ever diagnosed with HIV in Europe can therefore be adjusted upwards to over 1.4 million and, as you can see by the steepening of the epidemic curve is accelerating year on year.It confirms that the epidemic has been growing steadily since the late 1980s but since 2001 there has been a 2.5 fold increase in the total number of HIV infections reported in Europe.The HIV epidemic in Europe is not under control[1] 2011 data will be collected September 2012 and reported December 2012[2] HIV/AIDS surveillance in Europe 2010[3] France, Italy and SpainSources: ECDC/WHO. HIV/AIDS surveillance in Europe Stockholm: ECDC; 2011.2010 UNGASS country progress reports for the Russian Federation and Ukraine.2

3 Low access to HIV testing and counselling among populations most at risk in eastern Europe and central Asia- respondents who reported receiving an HIV test and learning the results in the preceding 12 months, selected countries 2005, 2007 and 2009Because of low access to (and low uptake of) HIV testing and counselling (especially among the populations most at risk of HIV infection and transmission – as demonstrated on this slide [1] ) not all HIV cases in Europe are diagnosed and reported.[1] Note: relatively small sample sizes and convenience sampling may bias the results of these studies among key populations.Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011

4 People living with HIV: fast growing numbers in eastern Europe and central AsiaEstimated number of people living with HIV in Europe,Europe (total estimated)2.4 million[2.1 million – 2.7 million]Eastern Europe and central Asia1.5 million[1.3 million – 1.8 million]Western and central Europe[ – ]Latest UNAIDS estimates of 2.4 million [1] people living with HIV in Europe [2] suggest that the reported cases represent just over half of all people living with HIV in Europe.Of these an estimated 1.5 million [3] are in eastern Europe and central Asia. A 2.5 fold increase from the [4] cases in 2001 and more than 10 times the number in 1991.There are an estimated [5] in western and central Europe. A somewhat more steady increase from the cases [6] in 2001 when the estimates for eastern Europe and central Asia were (for the first time) higher than those for the west.So unlike other Regions – including sub-Saharan Africa, the Caribbean and South and South-East Asia where the epidemic appears to be stabilizing and declining [2] – the eastern European and central Asian HIV epidemic continues to grow at an alarming and accelerating pace.[1] 2.1 million – 2.7 million[2] For 2011 reported in UNAIDS (2012) Together we will end AIDS[3] 1.3 –1.8 million[4] –[5] 780 000–960 000[6] –Source: UNAIDS. Together we will end AIDS. 2012

5 Estimated ART coverage in eastern Europe and central Asia among the worst globally (2011)ART also reduces risk of HIV transmission– Donnell D et al. Lancet, 2010, 375(9731):2092–2098The biggest challenge to the HIV response in eastern Europe and central Asia is access to effective and life-saving treatment.Although antiretroviral therapy (ART) has proved to be important in preventing HIV transmission (as is being confirmed elsewhere at this conference it is 96% effective in reducing heterosexual transmission in couples where one partner has HIV), access to ART in eastern Europe and central Asia is among the lowest globally.In 2011 only 23% of those believed to be in need of antiretroviral treatment were receiving it - well below the global coverage of 54% for low and middle income countries, less than half that in sub Saharan Africa and – unlike any other region – coverage did not increase in 2011 over 2010.Africans with HIV are more likely to get ARVs than eastern Europeans.Source: UNAIDS. Together we will end AIDS. 2012

6 Proportion of people who inject drugs receiving ART in low- and middle-income countries in the WHO European Region20022005200620102011*Number of reporting countries among 26 low- and middle income countries17212319Diagnosed people infected with HIV through injecting drug use(% among cumulative diagnosed HIV infections with a known transmission mode)46 000(71%)(77%)(59%)(59%)People infected with HIV through injecting drug use receiving ART(% among all people receiving ART with a known transmission mode)130(20%)4700(26%)53007700(21%)9000 (21%)Despite the crude measurement [1], these data reveal clear inequities in access to treatment for people who inject drugs.In 2011 people who inject drugs represented 59% of the cumulative number of reported HIV cases (with a known mode of transmission) but only 21% of those receiving antiretroviral therapy – this pattern of inequity is similar to previous years with little or no improvement since we first stated collecting these data in 2002.[1] Data from Russian Federation (the country with the largest number of people diagnosed with HIV) missing in 2002, 2010 and 2011.Missing countries (bold = a substantial number of people on ART)2002: Azerbaijan, Georgia, Hungary, Latvia, Poland, Romania, Russia, Turkey, Turkmenistan2005: Azerbaijan, Albania, Tajikistan, Turkmenistan, Uzbekistan2006: Albania, Turkmenistan, Uzbekistan2010: Bulgaria, Hungary, Romania, Russia, Turkey, Turkmenistan, Uzbekistan2011: Albania, Montenegro, Romania, Russia, Turkey, Turkmenistan, Uzbekistan* Preliminary ART data and 2010 HIV surveillance (case reporting) data

7 Infection increasing faster than treatmentCumulative number of reported cases and deaths (in thousands), WHO European Region, 1986–2010This shameful situation with regard to access to treatment means that in spite of efforts to increase the number of people on ART (to in 2010) treatment is not keeping pace with infectionsUnlike most other regions AIDS and AIDS-related deaths continue to rise in Europe – mainly due to increases in eastern Europe and central Asia, where the estimated number of people dying from AIDS-related causes has increased more than 10-fold between 2001 and 2010 [1] contributing to the cumulative total of reported deaths among AIDS cases in Europe.[1] from an estimated 7800 [6000–11 000] in 2001 to 90 000 [74 000–110 000] in 2010Sources: ECDC/WHO. HIV/AIDS surveillance in Europe UNGASS countryprogress reports for the Russian Federation and Ukraine. WHO/UNAIDS/UNICEFmonitoring and reporting on the Health Sector response to HIV/AIDS.7

8 HIV infection 1984–2010: WHO European RegionWe can see from case reporting, in the European region as a whole, a large increase in the cumulative number of cases since 1984 and no evidence of the epidemic declining.Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 201088

9 WHO European Region: geographical areasEastWestCentreThere are important differences with regard to the HIV epidemics in Europe.WHO and ECDC analyse the data according to three geographical areas that have been used since reporting first began in the mid 1980s.WEST, CENTRE and EAST and I will use these areas to describe some regional differences.Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 201099

10 HIV infections diagnosed 2010 in WHO European Region: geographic areaCharacteristics of casesWHO European Region*West*Centre*EastNumber of HIV cases25 6592 47890 198Rate per population13.76.61.331.7Percentage of casesAge 15–24 years**11.6%10.0%17%13%Female38%27%19%42%Transmission mode**Heterosexual43%24%***24%48%Men who have sex with men20%39%29%0.7%Injecting drug use23%4%Unknown16%41%7%So the overall pattern hides some important regional difference.We can see that in 2010 the East ( with 31.7 cases per population) had a far higher rate of reported HIV than either the West (6.6 cases) or Centre (1.3 cases)We can also see that injecting drug use is contributing to the epidemic in the East (43% of cases with know route of transmission) to a much greater extent than either West (4%) or Centre (4%).*No data from the following countries: Austria, Liechtenstein, Monaco.** Countries with no data on age or transmission mode excluded.*** Excludes individuals originating from countries with generalised epidemics.Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 20101010

11 HIV infections diagnosed 2010: WHO European Region cases per 100 000 popRates of new infections diagnosed (expressed here as population rates per ) in 2010 are generally much higher in the East than in the west or centreSource: ECDC/WHO. HIV/AIDS Surveillance in Europe, 20101111

12 HIV infection 2004–10:WHO European Region three geographical areasThe temporal trends illustrated here (as cases per population) show that whilst the rate [1] for the west and EU/EEA shows some stabilisation and rates in the centre and relatively low and stable; the epidemic is increasing at a dramatic rate in the East[1] adjusted for reporting delaysSource: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010Data not consistently reported or not available from: Austria, Monaco, Russian Federation.1212

13 HIV infections diagnosed 2010 WHO European Region: transmission mode and geographical areaImportant regional differences in the HIV epidemic are apparent when we consider mode of transmission.Although the main transmission routes vary by geographical area; HIV in all European countries disproportionally affects populations that are socially marginalised (such as migrants) and people whose behaviour is socially stigmatised (such as men who have sex with men shown here in green) or stigmatised and illegal (such as people who inject drugs shown here in red). Data confirms that the HIV epidemic in Europe remains concentrated in these key populations.In eastern Europe and central Asia 41% of cases newly reported in 2010 were people who inject drugs, slightly less than the 45% heterosexual cases. In recent years the east has experienced an increasing proportion of heterosexually transmitted HIV cases likely associated with sexual transmission from drug injectors. The proportion of cases among men who have sex with men in the East is low and likely to be under reported.In the western part of the Region, the epidemic remains concentrated among men who have sex with men (accounting for 39% of newly diagnosed cases in 2010) and migrants from countries with generalized epidemics (accounting for at least one third of heterosexually acquired infections).It is of note that many newly diagnosed cases of HIV are of unknown mode of transmission.Sources: ECDC/WHO. HIV/AIDS surveillance in Europe Russian Federation Ministry of Health and Social Development

14 HIV infections 2004–10: transmission groups in WHO European Region - EastTemporal trends by transmission routes illustrate the increases in heterosexual HIV are likely associated with sexual transmission from IDUs to non injecting partners. Several studies support this assumption and 50% of women living with HIV were likely infected by men who inject drugs.Mother to child transmission is amongst the lowest globally – the one big achievement in our region where elimination of mother to child transmission is achievable.Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010Data not consistently reported or not available from: Estonia, Russian Federation.1414

15 AIDS diagnoses 2004–10: WHO European Region three geographic areas and EU/EEAWhile diagnosed cases and AIDS mortality have declined in Western and Central Europe, in Eastern Europe and Central Asia the number of AIDS diagnoses continue to increase at an accelerating rate.The number of people dying from AIDS-related causes has increased more than 6-fold between 2001 and 2011 (from an estimated [11 000–26 000] in 2001 to 90 000 [74 000–110 000] in 2011). [1][1] For 2011 reported in UNAIDS (2012) Together we will end AIDSSource: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2010Data not consistently reported or not available from: West: Andorra, Denmark, Monaco, Sweden; Centre: Turkey; East: Russian Federation, Ukraine.1515

16 Vulnerability and marginalisationKey laws supporting or blocking universal access in countries in the east of the region, July 2010CountriesProtective lawsPunitive lawsA Laws and regulations that protect people living with HIV against discriminationB Non-discrimination laws or regulations that specify protections for vulnerable subpopulationsC Laws, regulations or policies that present obstacles to access to prevention, treatment, care and support for vulnerable subpopulationsD HIV-specific restrictions on entry, stay or residenceE Laws that specifically criminalize HIV transmission or exposureF Laws that criminalize same-sex sexual activities between consenting adultsG Laws deeming sex work ("prostitution") to be illegalH Laws that impose compulsory treatment for people who use drugs and/or provide for death penalty for drug offencesArmeniaYesNoAzerbaijanBelarusEstoniaGeorgiaKazakhstanKyrgyzstanLatviaLithuaniaRepublic of MoldovaRussian FederationTajikistanTurkmenistanUkraineUzbekistanHIV disproportionately affects populations that are socially marginalized and people whose behaviour is socially stigmatized or criminalised (people who inject drugs and their sexual partners; men who have sex with men; transgender people; sex workers, prisoners and migrants). The European HIV epidemic is concentrated in these key populations at higher risk.In some EE and CA countries over 50% of newly diagnosed infections in 2010 were among people who inject drugs. Repressive laws in the Region prevent people who use drugs from accessing treatment. The association between sex work and injecting drug use is accelerating the spread of HIV in the Region, as is the incarceration of people in these key populations.These problems are exacerbated by lack of political commitment to scaling up interventions for people who inject drugs, particularly needle syringe programmes and opioid substitution therapy.Here we show laws which enable (or act as barriers) to universal access in EECA countries. Protective laws relating to discrimination are – on the books at least – present in the majority of EECA countries, however punitive laws particularly against vulnerable populations are also common.Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011

17 Poor scale up of servicesServices to prevent diagnose and treat HIV infections are often not accessible to highly vulnerable and marginalised individuals and populations.In Eastern Europe and central Asia only 11% of all investment in HIV prevention is focused on key populations at higher risk.In many countries in the Region effective and evidence based harm reduction services for people who use drugs are not implemented, remain at small scale or in a pilot phase.Up to 60% of people living with HIV in some EE and CA countries are unaware of having been infected because of limited access to HIV testing and counselling services.Where HIV services do exist they are often poorly integrated with other health services, notably TB, drug dependence and hepatitis services.

18 Reported HIV infections acquired through injecting drug use: eastern Europe and central Asia (2010)Here we show the proportion of HIV infections attributed to injecting drug use for eastern European and central Asian countries inThese data confirm that IDU related HIV is a significant problem in all eastern European and central Asian countries.In all countries reporting data, between 40% and 70% of all HIV infections reported in 2010 were transmitted through injecting drug use.Data sources: ECDC/WHO. HIV/AIDS surveillance in Europe UNGASS countryprogress report of the Russian Federation 2010

19 Number of syringes distributed per IDU per year by needle and syringe programmes: eastern Europe and central Asia (2011)However, although injecting drug use is driving the epidemic in many countries, services to prevent HIV transmission for people who inject drugs have not been scaled up.This slide demonstrates that although some (Estonia, Kazakhstan, Kyrgyzstan and Uzbekistan) countries have reached 100 or more syringes per IDU per year; all eastern European and central Asian countries have failed to reach a recommended coverage of 200 syringes per IDU per year.Data source: WHO/UNAIDS/UNICEF monitoring and reporting on the Health Sector response to HIV/AIDS

20 Poor integration of servicesReducevulnerabilityand addressstructuralbarriers to accessingservicesBuild strongandsustainablesystemsLeveragebroader healthoutcomesthrough HIVresponseOptimize HIVprevention, diagnosis, treatment and care outcomesWhere HIV services do exist they are often poorly integrated with other health services, notably with TB, drug dependence and hepatitis services.Data source: WHO Regional Office for Europe. European Action Plan for HIV/AIDS

21 Percentage of people who inject drugs receiving opioid substitution therapy: eastern Europe and central Asia (2011)Here we show the percentage of people who inject drugs receiving opioid substitution therapy and note that no eastern European or central Asian countries provide coverage approaching the 40% recommended.Many struggle to provide OST to more than 1 or 2% of people who inject drugs and some (including Russia not included on this slide) do not provide any OST.HIV services are poorly integrated with drug dependence services and do not have access to OST – a vital tool to control HIV epidemics among and deliver services to people who inject drugs.* 2010 dataData source: WHO/UNAIDS/UNICEF monitoring and reporting on the Health Sector response to HIV/AIDS

22 TB and hepatitis co infectionTuberculosis and end stage liver disease caused by viral hepatitis C infection are among the leading causes of death among people living with HIV/AIDS - especially among those who are also drug dependent.People living with HIV are especially vulnerable to the impact of TB and multidrug-resistant TB.

23 HIV infection among all TB cases tested for HIV in the WHO European Region (2006-2010)In 2010, there were an estimated incident TB cases in Europe and central Asia - with an average estimated HIV prevalence of 5% (range of 0–25%) and nine countries with 8% or greater among people newly diagnosed with TB (including Estonia, Latvia, Lithuania, the Russian Federation and Ukraine – all countries with high rates of MDRTB).12% of all people newly diagnosed with TB in Europe and central Asia had multi drug resistant TB, the highest globally where the average is 3.4%, with peaks of up to 26% in some countries (and 28% in some settings). More than half the countries with a high burden of multidrug-resistant or extremely drug-resistant TB are in eastern Europe and central Asia.Among people being re-treated for TB, the percentage with multidrug-resistant TB is even higher, estimated at 37% across the region and as high as 65% in some countries.HIV is the greatest risk factor for developing TB and TB is responsible for more than a 25% of deaths among people living with HIV.In eastern Europe and central Asia the estimated coverage of ART among people with TB/HIV co infection is lower than that for all those with HIV infection.During the last 5 years cases of TB/HIV co-infection increased, from to – increasing 20% per year in the last five yearsSource: ECDC/WHO. Tuberculosis surveillance and monitoring in Europe, 2012

24 TB/HIV co-infection WHO European Region (2010)Timely detection and appropriate treatment is a challenge. Almost 16 000 (80%) TB/HIV cases out of an estimated 20 000 (range 16 000 – 25 000) were detected in 2010 and only 70% were offered antiretroviral treatment.TB is a leading killer among HIV-infected people.Timely detection and appropriate treatment is still a challenge for the Region.Only 74% of TB cases are tested for HIVOnly 80% of all estimated TB/HIV cases were detected in 2010 and only 70% of them were offered antiretroviral treatment.Source: ECDC/WHO. Tuberculosis surveillance and monitoring in Europe, 2012

25 HIV programme source of funding in Europe and central Asia, 2008 or 2009I will close my presentation with some funding issuesOver dependence on external and international funding has made countries in the Region vulnerable to changing funding priorities (e.g. global economic crisis; suspension and uncertainties of Global Funding; health priorities shifting from communicable to non communicable disease; donor fatigue and shifting donor priorities) and is unsustainable in the long run.Of 16 EECA countries, seven reported that they relied on international funds to finance 50% or more of their total HIV spending.Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011

26 Percentage of HIV programme spending on key populations originating from international funding sources, most recent yearHIV prevention programmes, in particular, have over reliance on international funding and prevention programmes for key populations at higher risk (people who inject drugs and their sexual partners; men who have sex with men; transgender people; sex workers, prisoners and migrants) are seriously under funded in many EE and CA countries.There is increasing concern in the Region that there will be less funding for prevention programmes for key populations.In Eastern Europe and Central Asia 91% of total spending on key populations at higher risk (people who inject drugs; men who have sex with men and sex workers) originated from international funding – compared to just 10% in the West and centre.West and centre: Belgium, Bulgaria, Croatia, Czech Republic, Hungary, Montenegro, Poland, Romania, Switzerland, United Kingdom.East: Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Ukraine, Uzbekistan.Source: UNAIDS/WHO. HIV/AIDS in Europe and central Asia. Progress Report 2011

27 Summary: HIV transmission in Eastern Europe and Central AsiaGrows at alarming ratePoor access to treatmentVulnerability and marginalisationPoor (integration of and scaling up) servicesTB (and hepatitis) co infectionFundingAlthough globally HIV appears to be stabilizing and declining the eastern European and central Asian HIV epidemic continues to grow at an alarming and accelerating pace.Lack of access to treatment is shameful with only 23% of those in need getting ARVs. Africans with HIV are more likely to get ARVs than eastern Europeans and central Asians.HIV disproportionately affects populations that are socially marginalized and people whose behaviour is socially stigmatized or criminalized.Services to prevent diagnose and treat HIV infections are often not accessible to vulnerable and marginalized individuals and populations.Where services do exist lack scale and are poorly integrated with other health services.Tuberculosis and end stage liver disease caused by viral hepatitis C infection are among the leading causes of death among people living with HIV/AIDS - especially among those who are also drug dependentAlthough global spending on HIV is increasing in eastern Europe and central Asia there is an over reliance on international funds and disastrously under investment in programmes for key populations at higher risk.2727

28 AcknowledgementsAndrew Ball Senior Strategy and Operations Adviser, HIV/AIDS Dept WHO, AIDS 2012 Conference Coordinating CommitteeFabiano Bertini AIDS 2012 International Conference Secretariat, International AIDS SocietySergii Dvoriak Director of the Ukrainian Institute on Public Health PolicyBernard Kadasia AIDS 2012 International Conference Secretariat, International AIDS SocietyAnna Koshikova Head of the Analytical Team, All-Ukrainian Network of PLWHJean-Elie Malkin Senior Adviser to Executive Director/Acting Director of the Regional Support Team for Europe and Central Asia UNAIDSMara Nakagawa-Harwood AIDS 2012 International Conference Secretariat, International AIDS SocietySerge Votyagov Executive Director of the Eurasian Harm Reduction Network (EHRN)I made this presentation on behalf of the Regional Working Group for eastern Europe and Central Asia and would like to acknowledge their contribution to the difficult task of presenting and prioritising all the challenges we face in eastern Europe and central Asia.I believe our distinguished panel will not help us understand what we need to need to do (and indeed what we are already doing) tp respond what may be the only HIV epidemic globally that remains out of control.

29 Question 1 to the panellistsHow can we scale up access to ART and increase early HIV diagnosis and treatment?How can we scale up access to ART and increase early HIV diagnosis and treatment?Model answerOptimising HIV prevention diagnosis, treatment and care; using simpler low cost regimens and effective delivery systems supported by the community – as prioritised in Treatment 2.0 and as demonstrated in countries such as Georgia. Elimination of mother to child transmission is realisable throughout the Region, including in Russia the country with the most cases of HIV in the Region. HIV testing and counselling to reduce the size of the undiagnosed population and the number of late HIV diagnoses is being scaled up – for example in Ukraine. Combination prevention, the use of a range of different approaches to reduce risk of infection, is gaining traction in many counties. Implementing the comprehensive package of interventions for drug injectors (including needle and syringe programmes and opioid substation therapy) is beginning to have an impact on HIV transmission through injecting drug use – for example in Estonia. Access to ART for IDUs in Ukraine as elsewhere in the Region is poor, but better in those also treated with OST (32%) than those who are not (10%).

30 Question 2 to the panellistsHow can we leverage broader health outcomes through the HIV response and build stronger and more sustainable health systems?Model answer The HIV response can have a positive impact on other health outcomes – for example in reducing the burden of tuberculosis and viral hepatitis. Integrating other health programmes and services can improve HIV outcomes. Integration and linkage between HIV and other health services and programmes have shown encouraging results. For example rapid progress has been made towards the elimination of mother to child transmission of HIV especially by integrating HIV prevention into maternal, newborn, child and adolescent health services and programmes. In % of all HIV-positive pregnant women in the Region received ART for prevention of mother to child transmission compared to the global average of 53% for low and middle income countries. Other integration models have been developed for example in Estonia (HIV and drug dependence) and Ukraine (HIV, TB and drug dependence).

31 Question 3 to the panellistsHow can we respond to reduce vulnerability and marginalisation?Model answer HIV in EECA disproportionately affects populations that are socially marginalized and people whose behaviour is socially stigmatized or criminalised (people who inject drugs and their sexual partners; men who have sex with men; transgender people; sex workers, prisoners and migrants). Barriers to accessing services are not insurmountable and the marginalisation, stigmatization and criminalisation of populations are neither acceptable nor inevitable. The majority of countries in the Region reflect or address human rights in their national AIDS strategies. Nevertheless implementing these laws remains a considerable challenge. Sexual relations between people of the same sex have been decriminalised in all but two countries in the Region. The European Region has been in the vanguard of forming innovative partnerships between international and other statutory agencies and civil society, including with communities of key populations at higher risk and people living with HIV/AIDS. Pan European networks and organizations have emerged (including ECUO and EHRN) and civil society has become a key actor in the formulation, promotion and delivery of change.

32 Question 4 to the panellistsHow can we respond to the funding crisis?Model answer The strategic investment frame work for HIV/AIDS developed by WHO, UNAIDS and the Global Fund and other key partners takes a targeted approach most suited to the European epidemiology and context; which prioritises areas of intervention and activities, recognises the synergies between the priority areas and with other programmes (TB, drug dependence etc.), pays particular attention to reducing vulnerability and structural barriers and recognises the efficiency gains in involving civil society. It propose a new investment model intended to support better management of national and international HIV/AIDS responses than exists with the present system and a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that addresses key populations and targeted interventions including harm reduction programmes for injecting drug users. In times of economic austerity it will be essential to rapidly apply new science, technologies and approaches to improve the efficiency and effectiveness of HIV programmes in countries. Globally increased access to HIV services resulted in a 15% reduction of new infections over the past decade and a 22% decline in AIDS-related deaths in the last five years. Investment in HIV services could lead to total gains of up to US$ 34 billion by 2020 in increased economic activity and productivity, more than offsetting the costs of ART programmes. Application of the investment framework at the national level and increased use of domestic funding, including national health insurance funds – for example in Estonia and Ukraine, are demonstrating solutions to the funding crisis.